JP6377617B2 - Improved surgical template - Google Patents

Description

  The present invention relates generally to the field of cranial surgery, including dentistry. More particularly, the present invention is used to protect teeth such as night guards or sports guards, or to facilitate and guide the installation of oral implants, or other oral surgery, such as maxillofacial surgery The present invention relates to a method and apparatus for making a dental or occlusal splin used by a surgeon to guide a procedure.

An example of a treatment workflow using guided surgery to attach an oral implant to a patient is presented.
1. The dentist examines the patient and obtains an X-ray image or scan data of the patient's oral condition.
2. Take an impression of the oral condition and use it to make a plaster model of the patient's jawbone and teeth.
3. A tooth setup that models the position, size, and shape of the desired prosthesis is formed on the gypsum model and then worn on the patient. It is then adjusted and optimized to meet the patient's oral status and clinical requirements.
4). Based on the tooth setup, an X-ray imaging guide is created. The x-ray imaging guide includes a radiopaque marker and is configured to be worn by a patient. A bite index is also formed, which is mounted between the x-ray guide and the patient's opposite jaw, holding the x-ray guide in the correct position in the patient's mouth.
5. The patient's oral status is then imaged using a double scan procedure. The patient is first scanned using a CT scanner with the x-ray guide and byte index in place. Only the X-ray imaging guide is then scanned. From the first scan, a computer model of the patient is generated. From the second scan, a computer model of the X-ray imaging guide is generated. Both models are then aligned with each other using the landmarks in the CT data resulting from the radiopaque marker. This makes it possible to present on the computer a detailed representation of the patient's oral condition, including the soft tissue surface profile (ie, the concave surface of the x-ray guide), alongside CT data representing bone and nerve structure To do.
6). The position and orientation of the implant is planned using a computer representation of the patient's oral condition, including surface details and CT data. Similarly, the position of any necessary anchor pins is planned at this stage.
7). A dental splint (also known as a surgical template in this case) is created that has the same shape as the radiographic guide but includes drill holes at the planned implant and anchor pin locations. Each drill hole is provided with a metal sleeve.
8). The dental splint is placed in the patient's mouth and used to guide the patient's jawbone perforation and placement of the dental implant.

  This treatment workflow is known to have several problems.

  First, to make a surgical template, an x-ray imaging guide must first be made. X-ray imaging guides are usually made by a laboratory that specializes in making dental components, not by the surgeon himself. This complicates and delays the treatment workflow for transportation. Production of an X-ray imaging guide is time consuming and expensive.

  Second, because the patient is usually already scanned at an early stage (see step 1 above), scanning with an x-ray guide further increases the patient's radiation dose. Furthermore, if the X-ray guide is not properly worn on the patient during the scanning procedure, a rescan must be performed, further increasing the radiation dose.

  Oral surgeons can choose to avoid these extra costs and complexity by installing implants in the traditional way, without using computer modeling and planning, but in modern treatment workflows Improved accuracy and predictability are lost. In fact, few surgeons choose this option.

  Therefore, what is needed is a current treatment workflow for creating dental splints for guided oral surgery or other applications that eliminates the need for radiographic guides.

  Embodiments of the present invention describe obtaining a set of 3D surface data representing a surface of a patient's oral condition and a dental splint configured to fit a portion of the surface of the patient's oral condition. Obtaining a virtual support structure model; obtaining planned hole position data describing a longitudinal axis of a set of one or more planned implant boreholes for the 3D surface data; and the one or more planned implants Automatically modifying the virtual support structure model to provide support for the guide hole corresponding to the borehole to the virtual support structure model; and surgically based on the modified virtual support structure model. A method of making a surgical template, including the step of making a template.

  In the following, aspects of the present invention will be described by way of example with reference to the accompanying drawings.

FIG. 1a shows a 3D surface model of the patient's oral condition. FIG. 1b shows the 3D surface model of FIG. 1a viewed from a second viewpoint.

FIG. 2a shows a horizontal slice of a distance map of 3D surface data of the patient's oral condition. FIG. 2b shows a coronal slice (left-right cross section) of 3D surface data of the patient's oral condition.

FIG. 3a shows the transparent support structure model and the 3D surface model of FIG. 1b below. FIG. 3b shows the support structure model of FIG. 3a without permeability.

FIG. 4 shows a horizontal slice of the distance map of the 3D surface data of the patient's oral condition including the indication of the dental arch.

FIG. 5a shows a panoramic maximum projection image of a distance map image. FIG. 5b shows the addition of a high point line that depicts the upper edge of the 3D surface model to FIG. 5a. FIG. 5c shows the high point line of FIG. 5b lowered by a certain distance to form a cut-off line used on the cheek side of the support structure.

FIG. 5d shows the cut-off line of FIG. 5c after smoothing. FIG. 5e shows a linear cut-off line used on the lingual side of the support structure. FIG. 5f shows the determination of the buccal or lingual voxel position on the support structure.

FIG. 6a shows the support structure model of FIG. 3a, where the buccal cutoff is applied based on the cutoff line of FIG. 5d and the lingual cutoff is applied based on the cutoff line of FIG. 5e. FIG. 6b shows the support structure model of FIG. 6a as viewed from a second perspective.

FIG. 7a shows a panoramic maximum value projection image of the distance map image of the second patient with the cut-off line drawn. FIG. 7b shows the cut-off line of FIG. 7a further lowered near the planned anchor pin site. FIG. 7c shows the cut-off line of FIG. 7b after smoothing.

FIG. 8 shows a process flow diagram of the cut-off line smoothing process.

FIG. 9a shows the rendered support structure model for the second patient with the cut-off line of FIG. 7b applied. FIG. 9b shows the rendered support structure model for the second patient with the cut-off line of FIG. 7c applied.

FIG. 10a shows a distance map image of the support structure model of FIG. 10b. FIG. 10b shows the support structure. FIG. 10c shows three viewpoints of the distance map image of the virtual component of FIG. 10d.

FIG. 10d shows the first virtual component. FIG. 10e shows the second virtual component.

FIG. 11a shows the support structure model before joining the support structure model material and the sleeve support material. FIG. 11 b shows the support structure model of FIG. 11 a after joining the support structure model material and the sleeve support material around the guide holes. FIG. 11c shows the joining of the support material around two adjacent guide holes in the support structure.

FIG. 11d shows the support structure model of FIG. 11b after punching.

Figures 12a-12c show virtual components that are added to or subtracted from the support structure model using Boolean operations on the surface.

FIG. 13a shows a combination of the virtual components of FIGS. FIG. 13b shows another combination of virtual components.

FIG. 14a shows a cross-sectional view of a tooth in the oral condition. FIG. 14b shows the tooth of FIG. 14a with a support structure model and shows the determination of undercut voxels to be removed. FIG. 14c shows the support structure model of FIG. 14b with the undercut voxels removed.

  Specific embodiments of the invention will now be described with reference to the accompanying drawings. This invention may, however, be embodied in many different forms and should not be construed as limited to the embodiments set forth herein; rather, these embodiments are intended to be exhaustive and complete with this disclosure. It is provided so that the scope of the present invention will be fully conveyed to those skilled in the art. The terminology used in the detailed description of the embodiments illustrated in the accompanying drawings is not intended to be limiting of the invention. In the drawings, like numerals refer to like elements.

  The following description focuses on embodiments of the present invention where a surgical template for guiding the placement of an oral implant can be applied. However, it will be appreciated that the present invention is not limited to the use of surgical templates, but can be applied to dental splints, such as the creation of protective mouth guards, or other similar applications.

  The following is a description of a preferred embodiment of the present invention, which is a method of making a surgical template without using an x-ray imaging guide. The same technique can be used to create a variety of dental splint types. First, a set of 3D surface data describing the surface of the patient's oral condition is acquired. Second, a virtual surgical template model is generated based on the 3D surface data and the planned implant and anchor pin locations. Third, a physical surgical template is created from the virtual surgical template model.

Determining the patient's oral status The surface of the patient's oral status is typically the occlusal dental arch above or below the patient, including the buccal, occlusal, and lingual soft tissues and teeth.

  3D surface data of the patient's oral condition can be obtained using a number of known optical or radiographic imaging techniques. For example, an intraoral optical scanner used in a patient's mouth generates 3D surface data suitable for use in this method. Alternatively, an optical scan of the impression of the patient's oral condition (processed as necessary to compensate for the impression that is a negative imprint of the oral condition), an optical scan of the die cast model of the patient's oral condition, surface There are high resolution 3DX X-ray computed tomography (CT) or magnetic resonance imaging (MRI) images of oral conditions combined with a detection algorithm.

  Both intraoral optical scanning and optical or tactile scanning of impression or die cast models have the advantage of minimal patient radiation exposure and high resolution surface scanning. CT and MRI scanners also provide the advantage of visualizing internal anatomy.

  The present invention uses a digital model based approach without CT data, uses a digital model based approach fused with CT data, or uses only CT / MRI images combined with a surface detection algorithm Can be used for guide implant placement.

  The 3D surface data 110 of the patient's oral condition is preferably stored as vertices and triangles that describe the triangulated surface shown in FIGS. 1a and 1b.

Generation of Support Structure Model A number of techniques can be used to generate a virtual surgical template model from 3D surface data of a patient's oral condition. The virtual support structure model can be used as an intermediate step in this process.

  Preferably, a distance map imaging method is used to process the 3D surface data to form a virtual surgical template model.

  A 3D distance map image 200 is formed by processing the 3D surface data of the patient's oral condition. This is done by starting with an empty voxel image having the same reference frame as the 3D surface described by the 3D surface data. Each voxel of the distance map image is assigned a value corresponding to the minimum distance of the voxel to the 3D surface described by the 3D surface data. FIG. 2 a shows a horizontal slice of the distance map of the patient's oral condition and the outline of the 3D surface 210. FIG. 2 b shows a coronal slice of the distance map of the patient's oral condition and the contour of the 3D surface 210.

  In one embodiment, for the lower jaw, positive values are assigned to voxels at or below the 3D surface (ie within the volume of 3D surface data representing the patient's tissue). Voxels above the 3D surface are assigned negative values. The farther the voxel position is from the 3D surface, the greater the value (negative or positive) assigned to the voxel. Other embodiments may include alternative voxel value configurations.

  When the distance map image is generated, a support structure model is generated that includes all voxels having values within a specific range of the distance map image. In one embodiment, to form a support structure, between a first value that represents a position close to the 3D surface and a position that is far from the 3D surface and whose magnitude is greater than the first value. All voxels with values (and thus at a certain distance from the 3D surface) are selected. The first value is chosen to select the distance from the 3D surface where the surface of the support structure model begins. The second value is chosen to define the thickness of the support structure, the thickness being determined by the difference between the first value and the second value. The resulting support structure model matches the 3D surface and fits the patient's oral condition. The greater the first value, the greater the tolerance between the 3D surface and the support structure. The tolerance results in a small amount of play. In a preferred embodiment, the tolerance is between 0.1 mm and 0.5 mm. FIGS. 2 a and 2 b show the contour lines of the first value 220 and the second value 230.

  In one embodiment, the first and second values are selected to generate a support structure model that includes all voxels whose distance above the 3D surface is between 0.1 mm and 2.1 mm. The resulting support structure model has a consistent thickness of 2.0 mm. 3a and 3b show an embodiment of a support structure model 310 that covers the 3D surface 320 of the patient's oral condition. The support structure model 310 has a leading edge 330. In FIG. 3a, the support structure model is depicted partially transparent so that the underlying 3D surface can be seen.

  The advantage of automatically generating the support structure model in this way is that it is accurate and robustly generated using a computer. Given only 3D surface data of the patient's oral condition, this technique can be used to quickly and accurately create a support structure model that matches.

  Since the support structure model must also be constrained along the dental arch, it does not extend all the way to the molars behind the patient's mouth. Rather, a backward limit is defined. In FIG. 4, limit line 420 indicates the posterior or posterior limit of the support structure model along the dental arch.

  In an alternative embodiment, subtractive techniques are used to generate a virtual surgical template model from 3D surface data of the patient's oral condition. This technique results in a predetermined shape having a shape that approximates a dental splint. Any shape that is larger than the patient's oral condition and small enough to be used as a support structure model would be suitable. Predetermined shapes are placed on the 3D surface so that they overlap. A Boolean operation is then performed to subtract the 3D surface of the 3D surface data from the predetermined shape. The resulting shape has approximately the same shape as the predetermined shape, but the surface matches the 3D surface. This resulting shape provides a suitable foundation for the support structure.

  In another alternative embodiment, augmentation techniques are used to generate a virtual surgical template model from 3D surface data of the patient's oral condition. This includes forming a binary image of the 3D surface, where voxels inside the 3D surface have a value of 1 and voxels outside the 3D surface have a value of 0. The resulting image is then expanded to create an enlarged binary image of the 3D surface. The original binary 3D surface is then subtracted from the expanded image to form a resulting support structure having a thickness based on the extent to which the expanded image is expanded relative to the 3D surface.

  In another alternative embodiment, a z-transfer technique is used to generate a virtual surgical template model from 3D surface data of the patient's oral condition. This involves using a 3D surface model overlaid with a second model of 3D surface data shifted in the Z axis. The geometric space between the two 3D surfaces can then be used to form a support structure. This results in a support structure model that has a surface that matches the oral condition of the patient and has a consistent thickness.

Support Structure Model Customization According to a preferred embodiment of the present invention, after a support structure model is generated, it can be further refined to include specific characteristics or features.

  Since the final surgical template is made from the support structure model, changing the characteristics of the support structure model will also change the characteristics of the final surgical template.

Support Structure Model Cut-Off Line In a preferred embodiment, the support structure model is configured to cover only the coronal portion of the patient's existing teeth or gum surfaces. A cut-off line is used to limit the support structure model in the tip direction. This is accomplished in the following manner.
1. First, as shown in FIG. 4, a dental arch 410 is determined for the distance map image 400. In an alternative embodiment, the dental arch is determined according to 3D surface data of the patient's oral condition. In another embodiment, the dental arch is indicated by the user.
2. A maximum projected image of the distance map image 400 is then generated along the dental arch 410 to form a panoramic image shown in FIG. 5a of the lower jaw similar to the orthopantomogram typically used by dentists. The ridge 500 is clearly visible.
3. As shown in FIG. 5b, the highest point (or coronal edge) along the top of the ridge 500 is recorded, forming a line 510 that defines the upper boundary of the 3D surface data. The highest point is determined as a transition point (for example, transition between a negative value and a positive value) from a pixel indicating a tooth quality to a pixel indicating an empty space in each perpendicular line of the panoramic image.
4). Then, in FIG. 5c, line 510 is lowered (away from the occlusal plane). This new line defines the buccal cut-off line 520 of the support structure model along the dental arch 410. For the corresponding maxilla, line 510 is not lowered, but is raised (again, away from the occlusal plane) to form cut-off line 520.
5. As shown in FIG. 5d, the cutoff line is smoothed. In one embodiment, a moving average algorithm is used to smooth the cutoff line.
6). The support structure model of FIGS. 3a and 3b is then modified to have a buccal edge corresponding to the buccal cutoff line.

  In a preferred embodiment, the buccal cut-off line is lowered by 1 mm to 4 mm. It should be understood that for the corresponding maxilla, the buccal cut-off line is raised rather than lowered.

  In the preferred embodiment, two cut-off lines are used. The cut-off line described above is used on the cheek side. On the lingual side, as shown in FIG. 5e, the cut-off line 530 is a straight line having a constant height. This straight line results in a larger lingual side of the support structure model and provides additional strength. As shown in FIG. 5f, an image is generated from the 3D surface to automatically determine which side of the support structure model is the buccal side 580 and which side is the lingual side 590, where each voxel position is represented by the tongue. The side or cheek side is determined. In one embodiment, determining the lingual or buccal side of the voxel is performed by determining on which side of the dental arch the voxel is located.

  An example of the resulting support structure model is shown in FIGS. 6a and 6b.

  In one embodiment, shown in FIG. 7a, in which the final surgical template is supported by an anchor pin inserted in the patient's jaw, the buccal cut-off line provides additional material around the anchor pin site. Will be corrected. In one embodiment, as shown in FIG. 7b, this lowers the cut-off line to include an area defined by a circle 740 around the anchor pin placement site 750 of the panoramic maximum projection image of the distance map image. Is done by. This step is only performed on the side where the anchor pin is located, for example the buccal side or the lingual side.

In one embodiment shown in FIG. 7c, the cut-off line of FIG. 7b is smoothed according to the following process shown in FIG.
-Calculate the moving average along the cut-off line as shown in step 810;
-In step 820, calculate the curvature of the cut-off line at each recording point to define the recesses and protrusions.
-In step 830, only the convex part of the line is maintained for the lower jaw and only the concave part is maintained for the upper jaw.

  A support structure model having buccal edges based on the unsmoothed cut-off line is shown in FIG. 9a, and a support structure model having buccal edges based on the smoothed cut-off line is shown in FIG. 9b. The second is clearly preferred for aesthetic and strength reasons and reduces the risk of injury to the patient.

Support Structure Model Guide Holes In a preferred embodiment, the support structure model is used to form a surgical template to guide borehole drilling so that an oral implant can be inserted into the patient's jawbone. Is done. Therefore, guide holes are formed in the support structure model. The guide hole may be fitted with a matching guide sleeve, which generally comprises a harder material and serves to guide the metal drill guide. Since the support structure model material around the guide hole needs to withstand some force due to interaction with the surgeon's instrument, the support structure model needs to be reinforced to support the guide sleeve. The reinforcement is done by adding virtual material to the support structure. Furthermore, the close fitting of the support structure model to the patient's dentition means that the top surface of the support structure model is very diverse.

For each guide hole, a guide sleeve support is added to the support structure model by the following procedure.
1. Based on the intended position of the borehole to be drilled in the patient's jaw and the position of the corresponding installed implant or anchor pin, the position of the guide hole in the support structure model is determined.
2. A distance map image 1010 (shown in FIG. 10a) of the support structure model 310 (an embodiment of which is shown in FIG. 10b) is provided.
3. A distance map image 1020 (shown in FIG. 10c) of the sleeve support shape 1030 (an embodiment of which is shown in FIG. 10d) is provided.
4). An image of a punch shape 1040 (an embodiment of which is shown in FIG. 10e) is provided.
5. The distance map image of the sleeve support shape is superimposed on the distance map image of the support structure model at a position corresponding to the longitudinal axis 1110 of the guide hole in the support structure model, and the total value of the distance map image exceeds the threshold value, A support structure model material 1120 is added. An example of the original support structure model is shown in FIG. An example of the modified support structure model after adding the sleeve support shape is shown in FIG.
6). When the distance map images of a plurality of sleeve support shapes overlap, the support structure model material 1120 is added at a place where the sum of the distance map images exceeds the threshold value. An example of a support structure model material connecting two sleeve support shapes is shown in FIG. 11c.
7). An image of the punch shape 1040 is superimposed on the distance map image of the support structure model at a position corresponding to the top of the guide hole in the support structure model, and the support structure model material is removed at all points in the punch image. An example of the support structure model of FIG. 11b after removing the punch material is shown in FIG. 11d.
8). When all of the above steps are completed for each of the guide holes, the support structure model image is converted to a 3D surface model. This process can be performed using a marching cube algorithm.
9. Thereafter, the 3D surface model 1240 of the top surface of the sleeve support (FIG. 12a) is added back to the 3D surface model of the support structure model at a position corresponding to the top of the guide hole. This provides a clean horizontal top surface at the top of the guide hole that contacts the drill guide.
10. The 3D surface model of the sleeve support space 1220 (FIG. 12b) is then subtracted to provide holes for drilling and implant placement. The sleeve support space shown in FIG. 12b also includes a portion 1210 that provides an interface between the final surgical template and the sleeve and provides a space for adhesive retention between the two.
11. Finally, to secure the sleeve to the template, the 3D surface of the adhesive tube 1230 (FIG. 12c) is subtracted so that an adhesive can be inserted between the final surgical template and the sleeve.
12 FIG. 13a shows all the components of FIGS. 12a-12c together in one image. FIG. 13b shows a collection of equivalent components used to form anchor pin guide holes in the final surgical template.
13. The original 3D surface data of the patient's oral condition is subtracted from the 3D surface model of the support structure model to remove material that is added to the support structure model in the above steps and adversely affects the close fit with the teeth. In one embodiment, slightly expanded 3D surface data of the patient's oral condition is supported by the support structure to ensure a small tolerance between the final created surgical template and the patient's oral condition. Subtracted from the model's 3D surface model.

  In one embodiment of Step 5 or Step 6 above, if the combined distance of two points in the distance map image from their respective closest points on the respective surface is less than 2 mm, additional support material is added. It is done.

  This technique for generating guide holes in the support structure model is also applicable to anchor pin guide holes that are used by anchor pins to secure a surgical template to a patient's jawbone.

Side sleeve opening In a preferred embodiment of the invention, the support structure is provided with a side opening. Corresponding openings in the dental splint being created are guide sleeves and / or guide tools (ie, tools having components that fit into the guide hole openings and support a drill bit or other instrument during a surgical procedure) Can be inserted into the guide hole from the side. Side openings are formed in the support structure model by Boolean subtraction of the box shape from the support structure. The subtraction results in a continuous opening from the guide hole to the outer surface of the support structure. The opening begins at the coronal edge of the support structure model and extends parallel to the opening having a height greater than, equal to, or less than the length of the guide hole. The centrifuge-mesial width is equal to or slightly less than the diameter of the guide hole to retain and fit the component into the guide hole. Side openings can be provided on either the buccal side or the lingual side of the support structure, but not both.

  In another embodiment, the lateral openings are formed by adjusting the cut-off line to provide a gap in the support structure model either on the buccal side or the lingual side. In such embodiments, the same dimensions as described above are used.

Undercut removal of the support structure model In a preferred embodiment, the support structure model is modified to ensure that it can be easily fitted onto the patient's dentition. As shown in FIGS. 14a and 14b, the abutment 1400 has a wider crown 1405 and narrows toward the neck 1406 and root. The support structure model 1410 formed according to the above method has a curved shape that matches the shape of the teeth. Therefore, it is considered that the opening of the support structure model at the cut-off point 1420 is narrower than the position where the tooth width is the widest. This makes it difficult, if not impossible, for a dentist to attach a surgical template corresponding to the support structure model without damaging the surgical template.

In a preferred embodiment, the support structure model is modified to remove portions 1420 that form an undercut of the support structure model. In one embodiment, this is accomplished by the following procedure.
1. The position of the widest width of the patient's teeth is calculated along the dental arch 410 of the distance map image. The height of the widest position is also determined by the panoramic maximum value projection image of the distance map image.
2. The portion of the support structure model that is closer to the dental arch 410 and below the height of the widest tooth position is removed as shown in FIG. 14c.

Creating a Physical Surgical Template Finally, a physical surgical template (or dental splint) is created based on a virtual surgical template model. The physical surgical template can be manufactured using additive manufacturing techniques. The advantage of this technique is the speed at which a physical surgical template can be made. Preferably, the physical surgical template is made as a physical replica of the virtual surgical template model using stereolithography. Other additive manufacturing techniques that can be used include inkjet 3D printers or SLS printers. Alternatively, a physical replica of the virtual surgical template model can be milled from a block of material.

Claims (9)

i) obtaining a set of 3D surface data (110) representing the surface of the patient's oral condition;
ii) obtaining a virtual support structure model (310) describing a dental splint configured to fit a portion of the surface of the patient's oral condition;
iii) obtaining planned hole position data describing a set of one or more planned implant borehole longitudinal axes (1110) for the 3D surface data;
iv) automatically modifying the virtual support structure model (310) to provide the virtual support structure model with support material (1120) for guide holes corresponding to the one or more planned implant boreholes. When,
v) creating a surgical template based on the modified virtual support structure model;
A method for producing a surgical template comprising:
For each borehole
vi) generating a 3D distance map image (1010) of the virtual support structure model (310), wherein the 3D distance map is a voxel image, and each voxel of the 3D distance map image is derived from the voxel; Having a value corresponding to the distance to the nearest position on the surface of the virtual support structure model;
vii) generating a 3D distance map image (1020) of the sleeve support shape (1030) for the guide hole, wherein the 3D distance map is a voxel image, and each voxel of the 3D distance map image is: Having a value corresponding to the distance from the voxel to the closest position on the surface of the sleeve support shape, the sleeve support shape has a longitudinal axis corresponding to the borehole;
viii) combining the 3D distance map image (1020) of the sleeve support shape with the 3D distance map image (1010) of the virtual support structure model;
If ix) binding voxel values for each point of the combined 3D distance map image corresponds to the lower than the minimum distance range, the step of modifying the virtual support structure model so that to add support,
A method further comprising: The virtual support structure model (310) according to claim 1, wherein the virtual support structure model (310) is modified so as to remove a portion that overlaps a punch shape (1040) that is disposed at a mouth of the guide hole and has the same longitudinal axis as the guide hole. Method. The method of claim 1 or 2, wherein the virtual support structure model (310) is modified to remove a portion that overlaps a guide hole shape (1220) having the same longitudinal axis as the borehole. The virtual support structure model (310) is modified to remove a portion overlapping an adhesive hole (1230) shape having an axis substantially perpendicular to the longitudinal axis (1110) of the borehole. The method according to any one of 1 to 3. The method according to any of the preceding claims, wherein the virtual support structure model (310) is modified to remove portions that overlap the 3D surface described by the 3D surface data (110).   The method of claim 5, wherein an enlarged 3D surface corresponding to the 3D surface data (110) is used.   The method of claim 1, wherein the support (1120) is added at a location where a combined voxel value at each point of the combined 3D distance map image corresponds to less than 2 mm. The method of any preceding claim, wherein the virtual support structure model (310) is modified to remove portions that form undercuts (1420).   9. A method according to any preceding claim, wherein the surgical template is a physical surgical template.